Scotland’s Mental Welfare Commission is to examine the use of physical restraint in NHS facilities after data gathered by The Ferret revealed a rise in recorded incidents by health boards.
Data released under a freedom of information request showed that six health boards across Scotland recorded a rise in the practice of physically restraining patients in mental health facilities between 2015 and 2018. The reported restraints were classified as “unplanned”, and in response to “adverse events”.
Restraint usually involves a team of up to three people putting weight on a patient to get control over the situation. It can lead to patients being hurt and reliving past traumatic experiences.
NHS Forth Valley reported the largest surge of 133 per cent. NHS Tayside recorded a 95 per cent increase, and recorded restraints also rose by 75 per cent within NHS Grampian, 64 per cent in Dumfries and Galloway, 50 per cent in Highland and 20 per cent in Fife.
|Dumfries & Galloway||263||316||439|
|Greater Glasgow & Clyde||Not disclosed|
|Ayrshire & Arran||380||389||351|
|Western Isles||Not disclosed|
|Orkney||Not recorded, but also no inpatient facility|
|Shetland||Not recorded, but also no inpatient facility|
NHS Greater Glasgow and Clyde, and NHS Western Isles failed to disclose figures. Other boards reported a decrease.
The Mental Welfare Commission for Scotland – the public body responsible for safeguarding the rights of people with a mental illness – is now planning to look at the data. “We would wish to examine the data you have obtained and seek to understand the reasons for any increase,” said a spokesperson.
“The commission is clear that restraint should only be used as a last resort, and we have issued specific guidelines on this subject.”
The Ferret investigation also uncovered gaps in reporting and data gathering. Despite guidance from the commission that patterns of restraint should be recorded to inform policy, some health boards said that they do not keep total numbers.
NHS Lanarkshire, Grampian, Shetland and Borders said that planned and unplanned restraint episodes are not recorded centrally to allow for analysis of trends. NHS Orkney declined to comment. There are no inpatient facilities in Shetland and Orkney, so any restraints would not be taking place in hospitals.
In England all mental health units are required by law to record the use of force, and the Secretary of State regularly publishes statistical information. But there is no statutory duty for Scottish healthcare providers to record restraints.
“While there is an expectation that episodes of restraint are recorded in clinical case records, there is currently no statutory duty,” said a Scottish Government spokesperson.
"An essential starting point for taking action is ensuring that reliable data is being gathered and analysed by all relevant authorities" Judith Robertson, Scottish Human Rights Commission
The Scottish Human Rights Commission called for more reliable data. “The commission is concerned about any increase in the use of restraint,” said chair Judith Robertson.
“An essential starting point for taking action is ensuring that reliable data is being gathered and analysed by all relevant authorities. The use of physical restraint in mental health facilities should only ever be a last resort.”
She added: “People’s rights in this area are protected by European and international human rights laws, including the UN Convention on the Rights of Persons with Disabilities, which also places a duty on the state to work towards the eradication of restraint altogether.”
The latest NHS figures revealed that numbers of full time equivalent mental health nurses have decreased across half of Scotland’s health boards since 2015 – and that since 2017 over 70 per cent of boards have seen a drop.
In 2015, a Unison Scotland report warned that difficulties reported by mental health nurses and support staff were being reflected in the quality of patient care. Staff highlighted that what used to be thought of as crisis management was becoming normal practice.
NHS Fife accepted that health boards were facing “recruitment issues”. Said a spokesperson: “In response to this the service has completed a workforce planning exercise and established a recruitment group to plan for the future.”
NHS Highland attributed the decrease in mental health nurses to a cut by the Scottish Government. There had been a “20 per cent reduction in nurse training places in 2012 leading to a smaller pool of registered mental health nurses (RMNs) across the country [which] coincided with the predicted peak in the cohort of RMNs reaching retirement age in 2017 onwards”.
There has also been a drop in the number of inpatients being admitted to mental health units across the majority of Scotland’s health boards, raising questions over whether those most in need of treatment are receiving it.
“My experience was dehumanising”
Hollie Berrigan, a former integrative counsellor in England who herself has recent lived experience as a patient, recalled what happened to her. “My experience of restraint as a patient was dehumanising, degrading and re-traumatising,” she said.
“A restraint can start off as an arm hold and end with four people on top of you, kneeling on the back of your knees and holding your legs down.
“For someone experiencing psychosis on an acute ward, restraint can at times be useful, by making them feel physically contained and cared for – this is something I have witnessed both as a professional, and a service user. However, it’s about understanding people’s narrative.
“If staff know that the person they’re working with can find restraint useful then it can be considered. However, if someone doesn’t have a positive relationship with touch and physical contact it can easily re-traumatise.
“To have that understanding of someone’s personal needs requires staff to take the time to read through an inpatient’s historical notes and have a conversation with their care coordinators. Starting a dialogue with that person is also important.
“Often professionals will surmise what may be useful for the individual without checking that out with them. Not one size fits all. People have a right to be involved in their own care and have a discussion about what is or isn’t useful for them.
“The impact on other patients – which is sometimes completely unavoidable – can instil a lot of fear. Staff can also get quite distressed by it themselves. Especially for newly qualified staff, restraining someone goes against what their core belief is about their job, and people can burn out easily.”
Amanda McLaren, whose son Dale took his own life after being discharged from Carseview mental health unit in Dundee, described the difficulties he faced accessing treatment he needed.
“Dale barricaded himself inside his home and attempted to hang himself – and that still wasn’t enough for them to admit him,” she told The Ferret.
“He received an urgent referral from his GP – who did everything he could – but he was agitated in Carseview because no one took the time to talk to him and help him to open up.”
In 2018 former patients at the facility told BBC Scotland that some staff used face-down restraint excessively and violently. Relations claimed family members had taken their own lives as the result of failings in the care they received at the centre, prompting NHS Tayside to launch an inquiry into standards of care and access to mental health treatment in September.
Keir Harding, an occupational therapist with over 19 years of experience working in mental health services across the UK, described what physical restraint meant. “Usually you have a team of up to three people putting weight on a patient,” he told The Ferret.
“Restraint is an attempt to get control, and people can get hurt – which isn’t the intention – but it is a risk. The loss of control for the patient can pose a psychological danger by replaying past traumatic experiences, and can damage relationships with carers and nurses.”
Harding also warned of the impact staff burnout can have on patient care. “In my experience, staff who feel unsafe are also more likely to restrain, and high staff turnover is a factor in this,” he said.
“If staff are run off of their feet on a ward and patients approaching them for help feel dismissed, they will find a way to show people how distressed they are, and that is often when situations can escalate.”
Restraint is an attempt to get control, and people can get hurt - which isn’t the intention - but it is a risk. Keir Harding, occupational therapist
Health boards cited a number of reasons for the rise in the use of restraint. Many highlighted their participation in the Scottish Patient Safety Programme for Mental Health, which aims to reduce harm to people using healthcare services.
According to NHS Forth Valley, contributing factors were “changes in our recording and reporting systems, an increase in the number of complexity of admissions within our acute mental health wards and the creation of new low secure inpatient facilities.”
The board added that figures reported by staff included “all classifications of restraint which includes cases where staff use verbal persuasion and gently guide or distract patients from potentially harmful situations”. It said all staff “follow relevant guidance and best practice in the use of physical restraint.”
NHS Grampian also highlighted the rising number of difficult patients. “Instances where staff have had no alternative but to use physical restraint have risen due to an increase in the amount of very challenging patients in their care,” said a spokesperson.
“Although the number of these patients is low, due to the severe nature of their illnesses some have had to be restrained on multiple occasions. Staff only use physical restraint as a last resort and in order to protect the safety and well-being of both the patient and those treating them.”
NHS Tayside argued that “fluctuations” in the number of physical restrain incidents were to be expected due to “increased staff awareness and training, and an increase in patients who require additional care due to their illness.” Staff were actively encouraged to record all incidents, it said.
NHS Dumfries and Galloway stated that restraint was “very seldom” used so percentage variations could reflect a very small number of incidents. “Recording methods can mean multiple incidents are documented for a single patient over a very short period,” the board said.
Margaret Pirie, who manages mental health services for NHS Fife, said: “An increase in restraints is likely to be reflective of an increase in staff reporting and changes made to the reporting form. Whilst there has been an increase in the number of restraints; there has importantly been a reduction in the types of restraint used and the length of time patients require restraint.”
NHS Highland stressed that its rates were lower than elsewhere, and one patient being frequently restrained could show as a percentage increase. It said there had been a reduction in the use of restraint in areas where it had introduced the patient safety programme – although incidents of aggression had not reduced. The programme was being rolled out in other areas.
The Scottish Government stressed it was trying to make mental health services better. “Everyone should be able to feel safe whilst receiving treatment or working in our mental health services, and the use of physical restraint should only ever be a last resort,” said mental health minister, Clare Haughey.
“As we work to further improve our mental health services the experience of patients, their families and staff are key to reshaping treatment and support.”
This article is part of The Ferret’s 2018 Storylab programme, which offered new writers the chance to develop a story from the seed of an idea through to final publication, with help from our experienced team of journalists.